Outcome and prognostic factors in patients with small cell lung cancer who receive third-line chemotherapy

Irinotecan monotherapy as third- or further-line treatment for patients with small cell lung cancer

BACKGROUND

Small cell lung cancer (SCLC) is a very aggressive cancer and recurrence is inevitable. Treatment of recurrent disease is important for improving the prognosis of patients with SCLC.

METHODS

We conducted a retrospective observational study to investigate the efficacy and safety of irinotecan monotherapy as third- or further-line treatment in patients with SCLC.

RESULTS

Data of 15 patients who had received irinotecan monotherapy as third- or further-line treatment between 2004 and 2019 were analyzed. The median progression-free survival duration (95% confidence interval) from the initiation of treatment with irinotecan was 2.7 (1.4-3.8) months, and the median overall survival duration (95% confidence interval) from the initiation of irinotecan treatment was 10.0 (3.9-12.9) months. Partial response, stable disease or non-complete response/non-progressive disease, and progressive disease were observed in 1, 6, and 8 patients, respectively. Adverse events ⩾ grade 3 in severity were observed in 2/2 (100%) patients who were homozygous for UGT1A1 mutation, 2/3 (66.7%) patients who were heterozygous for UGT1A1 mutation, 4/6 (66.7%) patients who had wild-type UGT1A1, and 2/4 (50.0%) patients in whom the UGT1A1 mutation status was unknown.

CONCLUSION

Our results suggest that irinotecan monotherapy can be a useful alternative treatment option in the third-line setting for patients with SCLC.

Real-world treatment patterns and outcomes in small-cell lung cancer: a systematic literature review

Background

Small-cell lung cancer (SCLC) accounts for 12-15% of lung cancers and is associated with poor survival outcomes and high symptom burden. This study employed a broad, systematic search strategy and timeframe to identify evidence on real-world treatment patterns and outcomes for SCLC outside the USA, including understanding sub-populations such as extensive-stage (ES) or limited-stage (LS) disease.

Methods

Databases (MEDLINE, Embase, and EBM reviews) were searched for journal articles published in the English language between 1 January 2000-1 March 2020 and supplemented by hand searching of conference abstracts and posters presented at conferences between 1 January 2016-1 March 2020 reporting real-world treatment outcomes in patients with SCLC. A targeted clinical guideline review was also completed.

Results

One-hundred studies provided quantitative data; 57 were available as full-text articles, whilst the remaining 43 were presented as abstracts or posters. The majority (80 studies, 80%) of included studies reported treatment in the first-line setting, where platinum-based chemotherapy and chemoradiotherapy was the most commonly used treatment strategy, in line with current treatment guidelines in SCLC. First-line treatments were found to have a high response rate; however, most patients relapsed early. No studies reported treatment or outcomes with immune-oncology therapies. Second-line treatment options were very limited, and primarily consisted of either re-treatment with first-line regimen or topotecan, but the prognosis for these patients remained poor. Outcomes were particularly poor amongst those with ES or relapsed disease vs. LS disease.

Conclusions

SCLC treatment patterns and short survival outcomes have remained constant over the previous 20 years. Due to the search timeframe, none of the studies identified reported on the impact of recently approved immune-oncology therapies in SCLC. Further data is needed on the impact of immunotherapies on treatment patterns and real-world outcomes in SCLC.

[Small Cell Lung Cancer]

Small cell lung cancer is an aggressive cancer entity and characterized by rapid progression, early distant metastasis and poor prognosis. Only the minority of patients presents with a non-metastatic stage disease where chemo-radiotherapy or - in very selected cases - even surgical resection may be discussed. For most patients, the efficacy of systemic therapy is crucial. However, although most patients respond to platinum doublet chemotherapy, virtually all patients with metastatic disease eventually develop tumor progression for which there are limited treatment options. Recently and for the first time since decades, the systemic approaches have been enriched by the implementation of immunotherapy. Moreover, novel therapeutic approaches such as new cytotoxic agents or further immune modulatory strategies are being tested in clinical studies that might broaden our treatment options in the future even further.

Paclitaxel for treatment of advanced small cell lung cancer (SCLC): a retrospective study of 185 patients

Background

Etoposide-/platinum-based chemotherapy is the standard first-line treatment for extensive-disease small cell lung cancer (SCLC), but responses are short-lived and subsequent options limited. Here, we present our experience with paclitaxel in advanced treatment lines.

Methods

We retrospectively studied the clinical course of all paclitaxel-treated SCLC patients between 2005 and 2015 in our institution. Prognostic and predictive factors were analyzed by Kaplan-Meier and Cox regression analyses.

Results

A total of 185 patients [119 men, median age 65 years, median ECOG performance status (PS) 1] were identified. One hundred and sixty-eight patients had extensive disease (ED) at the time of paclitaxel therapy. Paclitaxel was mainly given as third- or fourth-line therapy (93%). The response rate (RR) was 17% and disease control rate (DCR) 28%. Patients reached a median progression-free survival (PFS) of 1.6 (95% CI: 1.4-1.8) months and median overall survival (OS) of 3.3 (95% CI: 2.8-3.9) months. Main toxicities were fatigue (25%) and polyneuropathy (17%). Dose reduction of ≥25% was associated with shorter PFS [1.9 (95% CI: 1.5-2.3) vs. 1.4 (95% CI: 1.3-1.5) months; P=0.004]. Further independent predictive factors for PFS were gender, age, and hepatic/brain metastases (P<0.05). Tumor response to paclitaxel, PS, number and location of metastases, dose reduction, and smoking history were significant factors for OS in univariable analyses (P<0.05), while PS, dose reduction, status of cerebral/hepatic metastases, tumor response, and smoking history were retained as independent prognostic factors in multivariable testing. Notably, ECOG PS 2 patients had toxicity rates similar to ECOG PS 0-1 patients (63% vs. 62%), as well as a comparable DCR (29% vs. 28%), which was associated with prolonged survival (4.5 vs. 3.2 months for refractory cases, P=0.034).

Conclusions

Paclitaxel has clinically relevant activity in heavily pretreated SCLC. While patients with good PS and no cerebral/hepatic metastases derive the greatest benefit, ECOG PS 2 per se should not be used as a criterion to exclude patients.

The Hemoglobin, Albumin, Lymphocyte, and Platelet (HALP) Score in Patients with Small Cell Lung Cancer Before First-Line Treatment with Etoposide and Progression-Free Survival

BACKGROUND The hemoglobin, albumin, lymphocyte, and platelet (HALP) score is a prognostic factor in patients who have some types of malignant tumors. The aim of this study was to investigate the prognostic significance of the HALP score in patients with small cell lung cancer (SCLC) before first-line treatment with etoposide. MATERIAL AND METHODS A retrospective study included 178 patients with SCLC who received first-line chemotherapy with etoposide between September 2015 and May 2019. The baseline clinical characteristics and blood parameters were recorded. Univariate and multivariate analysis and Kaplan-Meier plots were used to identify the factors associated with progression-free survival (PFS). RESULTS The optimal cut-off values of the HALP score was determined by X-tile software to be 25.8. Univariate and multivariate analysis showed that in 178 patients, the HALP score, body mass index (BMI), and serum albumin levels had no prognostic significance. In the patient age group <65 years, a BMI ≥24 kg/m² was an independent prognostic factor (HR, 1.943; 95% CI, 1.251-3.018) (P=0.003). In the patient age group ≥65 years, a HALP score >25.8 was an independent positive prognostic factor for outcome following first-line treatment with etoposide (HR, 0.483; 95% CI, 0.270-0.865) (P=0.014). CONCLUSIONS In patients <65 years with SCLC who underwent first-line treatment with etoposide, a BMI ≥24 kg/m² an independent prognostic factor, and in patients ≥65 years, a HALP score >25.8 was an independent predictor of improved outcome, associated with increased PFS.

Clinical Parameters for Predicting the Survival in Patients with Squamous and Non-squamous-cell NSCLC Receiving PD-1 Inhibitor Therapy

We explored the associations between progression-free survival (PFS) after the initiation of PD-1 inhibitor therapy and the clinical parameters in patients with NSCLC. We reviewed the clinical data of patients with NSCLC treated with PD-1 inhibitor. Data of a total of 36 patients, including 16 patients with squamous cell NSCLC and 20 patients with non-squamous cell NSCLC were reviewed. Multivariate analyses identified EGFR status, C-reactive protein (CRP), and PFS following previous therapy as being significantly associated with the PFS after initiation of PD-1 inhibitor therapy in patients with NSCLC. In patients with squamous cell NSCLC, the blood neutrophil/lymphocyte ratio (NLR), serum lactate dehydrogenase (LDH), serum C-reactive protein (CRP), and PFS following previous therapy were identified as being significantly associated with the PFS after initiation of PD-1 inhibitor therapy. However, none of these associations, except for PFS following previous therapy, were found in patients with non-squamous cell NSCLC. NLR, LDH and CRP were associated with the PFS after initiation of PD-1 inhibitor therapy in patients with squamous cell NSCLC, and PFS following previous therapy was the common parameter associated with the PFS after initiation of PD-1 inhibitor therapy in both squamous-cell NSCLC and non-squamous-cell NSCLC patients.

The effect of post-progression survival on overall survival among patients with sensitive relapse of small cell lung cancer

Recent studies have suggested that, among patients with advanced lung cancer, subsequent treatment after failure of first-line or second-line chemotherapy has a greater effect on overall survival (OS) than tumor shrinkage or progression-free survival (PFS). However, no studies have examined this issue among patients with sensitive relapse of small cell lung cancer (SCLC). We retrospectively evaluate 77 patients with sensitive relapse of SCLC who received second-line chemotherapy after first-line platinum doublet chemotherapy between January 1999 and November 2013. The analyses included patient characteristics, treatment parameters, tumor shrinkage, PFS, post-progression survival (PPS), and OS. Spearman rank correlation analysis and linear regression analysis revealed that PPS was strongly correlated with OS (r = 0.91, p < 0.01, R² = 0.96), PFS was moderately correlated with OS (r = 0.58, p < 0.01, R² = 0.28), and tumor shrinkage was weakly correlated with OS (r = 0.34, p < 0.01, R² = 0.12). A multivariate Cox proportional hazards model with a stepwise regression procedure revealed that PPS was significantly associated with age at the start of second-line chemotherapy, best response to second-line and third-line chemotherapy, and the number of regimens after progression beyond second-line chemotherapy (p < 0.05). These findings suggest that PPS has a stronger effect than PFS on OS among patients with sensitive relapse of SCLC. Thus, response to second-line chemotherapy and subsequent treatment for disease progression after second-line chemotherapy may be important factors that influence OS.

Body mass index and mortality in lung cancer patients: a systematic review and meta-analysis

Studies examining the relation of body mass index (BMI) and mortality in patients with lung cancer have shown diverse results. We conducted a meta-analysis to investigate the association using all available studies from January 1982 to October 2016. PubMed and EMBASE were searched to identify relevant studies. We calculated the summary hazard ratio (HR) and 95% confidence interval (CI) using random effects model. The dose-response relationship was assessed by random effects meta-regression model. Fifty-five articles from 51 studies involving 3 152 552 subjects (males, 54.8%) were included. The pooled results suggested that on average a high BMI decreased risk of death from lung cancer or all-cause. Each 5 kg/m² increase in BMI had a 12% lower risk of lung cancer-specific mortality (HR=0.88, 95% CI: 0.75-1.02, P=0.09) and a 14% lower risk of all-cause mortality (HR=0.86, 95% CI: 0.77-0.96, P<0.01). When stratifying by ethnicity, each 5 kg/m² increase in BMI was associated with 22% and 28% reduction, respectively, in the risk of lung cancer-specific mortality (P<0.01) and all-cause mortality (P<0.01) in Asians, but no association was found in Westerners (P=0.51 and P=0.53, respectively). In conclusion, lung cancer patients with a higher BMI have a longer survival than those with a lower BMI. Considering the significant heterogeneity between included studies, future studies are needed to confirm these findings.

Outcomes and prognostic factors of chemotherapy for patients with locally advanced or metastatic pulmonary squamous cell carcinoma

BACKGROUND

Pulmonary squamous cell carcinoma has not benefited from improvements in chemotherapy over the past decade, compared with non-squamous non-small-cell lung cancer. Nowadays, treatment strategies differ between squamous and non-squamous non-small-cell lung cancers. This study aimed to investigate the percentage of patients treated with first-, second-, or third-line chemotherapy and the characteristics of patients for whom chemotherapy has been beneficial.

METHOD

Data on patients with stage IIIB or IV squamous cell carcinoma diagnosed between June 2007 and March 2015, and on patients who had received first-, second-, or third-line chemotherapy between June 2007 and November 2015 at our hospital, were retrospectively extracted from our institutional medical charts. We also compared patients who were treated with chemotherapy (chemotherapy group) and patients who were not (non-chemotherapy group) using multivariate logistic regression and multivariate Cox hazard analyses, respectively.

RESULTS

During the study period, 103, 63, and 32 patients received first-, second-, and third-line chemotherapy, respectively. Fifty-one patients did not receive chemotherapy. Factors predicting unlikely chemotherapy included age ≥75 years, Eastern Cooperative Oncology Group (ECOG)-performance status (PS) ≥2, Charlson comorbidity index ≥2, hemoglobin <12.2 g/dL, red cell distribution width ≥13.9%, and serum sodium <140 mEq/L. Factors predicting survival for each line of chemotherapy included the following: ECOG-PS ≥2 for first-line; ECOG-PS ≥2 and lymphocyte count for second-line; and ECOG-PS ≥2, body mass index <18.5 kg/m2, and hemoglobin and lactate dehydrogenase levels for third-line.

CONCLUSION

Approximately 66% of patients received first-line chemotherapy. Of those, 66% and 33% received second- and third-line chemotherapy, respectively. ECOG-PS was always an essential prognostic factor when considering introducing chemotherapy and proceeding with additional chemotherapy. Other markers, such as lymphocyte count, body mass index, anemia, and lactate dehydrogenase level, may be useful depending on the patient and line of chemotherapy.

Retrospective analysis of outcomes and prognostic factors of chemotherapy for small-cell lung cancer

BACKGROUND

Small-cell lung cancer (SCLC) is responsive to initial chemotherapy but becomes resistant to cytotoxic drugs. The aim of this study was to evaluate what proportion of patients with SCLC had received the first- and further-line chemotherapy and which patients had benefited from chemotherapy.

METHODS

We retrospectively reviewed medical records of patients with SCLC who had been treated with the best supportive care alone and the first-, second-, or third-line chemotherapy at the Osaka Police Hospital from June 2007 until March 2015.

RESULTS

Among 145 patients diagnosed with SCLC and eligible for analysis, 118 patients received chemotherapy. We added five patients who initiated the second-line chemotherapy during the study period at our institution. Sixty-five and 31 patients received the second- and third-line chemotherapies, respectively. Multivariate logistic regression analysis detected age ≥75 years (odds ratio, 2.80; 95% confidence interval, 1.01-7.75; P=0.047) and European Clinical Oncology Group Performance Status (ECOG PS) 3-4 (14.3; 4.86-41.9; P<0.01) as factors disturbing the introduction of chemotherapy. Multivariate Cox hazard analyses also detected ECOG PS 2-4 (3.34; 2.00-5.58; P<0.01) as a factor decreasing overall survival after the first-line chemotherapy, and C-reactive protein level ≥1.0 mg/dL (2.67; 1.30-5.47; P<0.01) and progression-free survival after the first-line chemotherapy ≥6 months (2.85; 1.50-5.43; P<0.01) as factors influencing overall survival after the second-line chemotherapy.

CONCLUSION

Approximately two-thirds and one-third of the patients who receive chemotherapy proceed to the second- and third-line chemotherapies, respectively. Several factors, such as age, ECOG PS, C-reactive protein level, and progression-free survival after previous treatment may be useful when considering the introduction of further-line chemotherapy.

First-line chemotherapy in patients with metastatic gastroenteropancreatic neuroendocrine carcinoma

Background and aim

To investigate the efficacy of platinum-based chemotherapy in patients with metastatic gastroenteropancreatic neuroendocrine carcinoma (mGEP-NEC) and define predictive and prognostic factors.

Methods

Twenty mGEP-NEC patients were treated with cisplatin or carboplatin/etoposide between April 2010 and October 2014. Both large-cell and small-cell histologies were included. Cisplatin 25 mg/m² was administered on days 1–3 followed by etoposide 100 mg/m² on days 1–3 every 21 days. Carboplatin 300 mg/m² was administered on day 1 followed by etoposide 100 mg/m² on days 1–3.

Results

Of the 19 evaluable patients, 13 obtained a partial response, four showed stable disease, and two progressed. Median overall survival (mOS) was 13.5 months and median progression-free survival (mPFS) was 10.9 months. Gallium-68 positron emission tomography/computerizsed tomography-positive patients had a higher, albeit not significantly, OS than those with negative results (75% vs 34.3% at 18 months; P=0.06). mPFS was 19.3 and 6.3 months (P<0.01) in mGEP-NEC patients with Ki67 ≤55% or >55%, respectively. mOS was 8.1 months in the latter group but was not reached in the Ki67 ≤55% group (P-value =0.039). Patients with a lower body mass index (BMI) had a better prognosis in terms of both OS and PFS. Patients with BMI ≥25 had a mOS of 11.7 months (P=0.0293) and a mPFS of 6.2 months (P=0.0057).

Conclusion

Platinum-based chemotherapy showed good efficacy in mGEP-NEC patients. Those with Ki67 ≤55%, positive Gallium-68 positron emission tomography/computerized tomography and BMI <25 had a better prognosis.

Topotecan for Relapsed Small-cell Lung Cancer: Systematic Review and Meta-Analysis of 1347 Patients

Topotecan is the most reliable chemotherapy regimen for relapsed small-cell lung carcinoma (SCLC). The efficacy and adverse effects of topotecan as reported by previous studies varied greatly. The inclusion criterion was a prospective study that was able to provide data for 6-month over-all survival (OS) rate, 1-year OS rate, objective responses, and/or adverse effects of single agent topotecan as a second line chemotherapy for SCLC, written in English language as a full article. Any topotecan regimen were allowed. Binary data were meta-analyzed with the random-model generic inverse variance method. We included 14 articles consisted of 1347 patients. Pooled values were estimated as follows. <Refractory relapse> Six-month OS rate: 37% (95% CI: 28-46%). One-year OS rate: 9% (95% CI: 5-13%). Response rate: 5% (95% CI: 1-8%). <Sensitive relapse> Six-month OS rate: 57% (95% CI: 50-64%). One-year OS rate: 27% (95% CI: 22-32%). Response rate: 17% (95% CI: 11-23%). <Adverse effect> Grade III/IV neutropenia 69% (95% CI: 58-80%). Grade III/IV thrombopenia 41% (95% CI: 34-48%). Grade III/IV anemia 24% (95% CI: 17-30%). Non-hematorogical events were rare. Chemotherapy-related death 2% (95% CI: 1-3%). In conclusion, Topotecan provided a possibly promising outcome for sensitive-relapse SCLC and poor outcome for refractory relapse SCLC. Adverse events were mainly hematological.